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At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).

Fundal tone

Lochia

Transcutaneous bilirubin

Engorgement

Vital Signs

Bladder distension

Answer and Explanation

Correct Answer : A,B,E,F

A. Fundal tone assessment helps detect uterine atony.

B. Lochia assessment monitors postpartum bleeding.

C. Transcutaneous bilirubin is not assessed in the immediate postpartum period.

D. Engorgement relates to breastfeeding and is not a priority in the fourth stage.

E. Vital signs are crucial to monitor for hemorrhage or shock.

F. Bladder distension can affect uterine contraction and bleeding.

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Correct Answer is C

Explanation

A. Genetic testing is not necessary to determine if the twins are identical. Identical twins come from the same egg, while fraternal twins come from separate eggs.

B. The size difference alone does not determine whether twins are identical or fraternal.

C. Dizygotic twins (fraternal twins) are always of different sexes. This is because they are fertilized by two separate sperm and develop from two separate eggs.

D. Monozygotic twins (identical twins) occur when one fertilized egg splits into two embryos. The fact that they are different sexes rules out the possibility of monozygotic twins.

A. 3 lbs per week for each week of pregnancy B. 35-40 lbs throughout the entire pregnancy C. 15-20 lbs throughout the entire pregnancy D. Less than a 1lb per week for each week of pregnancy.

Correct Answer is C

Explanation

A. 3 lbs per week is too high for someone with a BMI of 16 and could lead to excessive weight gain.

B. 35-40 lbs is too broad and may not be suitable for this patient's low BMI, which typically requires a more controlled approach.

C. For a patient with a BMI of 16 (underweight), the recommended weight gain during pregnancy is generally between 28-40 pounds, but given the patient's lower weight, 15-20 lbs is a realistic goal for weight gain, allowing for healthy fetal development.

D. Less than 1lb per week could be too slow, potentially leading to insufficient fetal growth.

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At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).

Nursing Test Bank

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Explanation

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